The Supreme Court determined that the amount discounted under the guise of a referral discount from a medical institution does not fall under the compensation subject of the actual medical insurance.
According to the Insurance Law Review published by the Research Institute on the 15th, the Supreme Court ruled on Oct. 31 that the amounts reduced due to referral discounts do not qualify for compensation under actual medical insurance.
When a medical institution offers a discount on the pre-notified medical cost for a specific patient under the guise of a referral discount, the final amount after the discount is considered an expense borne by the patient according to the individual agreement between the medical institution and the patient, the Research Institute explained.
According to the terms, the compensation subject under the insurance is the expense borne by the insured for non-covered medical costs, which may be determined based on the provisions of the individual medical contract between the medical institution and the patient.
The Research Institute noted, "The Supreme Court also considered that, as a type of property damage insurance that compensates for financial losses, it may contradict the principle of the insurance system for the insured to gain more than just compensation for their losses."
The Supreme Court also stated that the amount refunded by the pharmaceutical company to the insured for the immune-oncology drug prescribed for treatment under the risk-sharing system does not qualify for compensation under actual medical insurance, the Research Institute reported.
If the insured does not actually incur the expense corresponding to the refund amount by receiving a partial reimbursement of drug costs from the pharmaceutical company under the risk-sharing system, that refund amount is not included in the losses compensated by the actual medical insurance.
Baek Yeong-hwa, senior researcher at the Research Institute, said, "The Supreme Court ruling is valid when viewed against the principles of actual compensation and the prohibition of profit, and it should be noted that the basic purpose of actual medical insurance is to ultimately compensate for the expenses that the insured actually bears."